Medicare advantage plan

[MichaelB]

wrong ,,, did you read the links.

did you google it ?

in theory they are supposed to but YOU DONT HAVE GOVT MEDICARE to say when you are denied what govt medicare would have allowed in your case .

not everything is black and white . i witnessed it first hand

many things if you google it are denied , yet the problem is you can’t say what government medicare would have done .

that is why law makers are trying to get this corrected fully .so far no luck on a wide scale of having one central gate keeper for both.

saying we cover the same things is only in theory until they don’t and the advantage plan gate keepers deny you.

hospitals are seeing way more denials from advantage plans then govt medicare

Sorry, but not “wrong”. Instead of Google I checked with the source, CMS. Here’s a fact sheet (here) that compares traditional Medicare with Medicare Advantage. Here is the comparison of coverage:

Medicare

Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams.

Medicare Advantage

Plans must cover all medically necessary services that Original Medicare covers. Plans may also offer some extra benefits that Original Medicare doesn't cover - like certain vision, hearing, and dental services.

I’m not advocating for Medicare Advantage. It does have shortcomings, but we should try to keep it fact based.

 

[mathjak107]

that proves nothing .

why do so many advantage plan denials have to try to be appealed .

the answer is because they are not the same in practice.

it is a battle getting them to cover a lot of things they should but don’t want to.

a for profit gate keeper is going to challenge you wherever they can get away with it.

don’t believe for a second it’s the same because they say so in literature

you may have to fight months to get a reversal while your health is at stake .

only to possibly lose

 

[Gumby]

Moderator note: How about some of you guys stop shouting? Disagree all you want, but please be polite about it.

 

[Spock]

I agree with NXR7. Medicare Advantage plans are required to administer the same coverage as Medicare traditional. They can, and do, limit their provider network, but they cannot refuse to cover a treatment or service covered by Medicare.

Medicare Advantage plans often include drug coverage and other services not covered by Medicare, such as dental.

I think that is far too narrow criteria to declare them the same.
Medicare Advantage is more of a side exit from the medicare system.
Medigap plans dovetail with Plans A and B to cover where base medicare A and B do not (cover the "donut holes" in A/B coverage).

In Medicare Advantage it is the whole coverage. There is "no A and B does this first" in Advantage plans. Medicare pays the Advantage insurer a flat rate per person and then the insurer generates a profit based on the difference between what Medicare pays them and what the insurer pays out.

Medicare does specify minimum coverages in Advantage plans, but that is just analogous to the government requiring employee private health plans to cover mental health or whatever other benefits they specify insurers must provide.

Another similarity to private employee health plans is Advantage plans have an annual open enrollment where you can change Advantage plans and insurers where Medicare does not.

 

[mathjak107]

actually here in new york we are allowed to swap from advantage to medicare or the other way with no medical underwriting.

but we pay a lot more for our supplements

 

[CRLLS]

The problem here is one of terminology. There is "Original Medicare" and "Medicare Advantage", part A & Part B vs Part C respectively. Both are defined under the law under the term Medicare. I'll guess that most of us simply call Original Medicare, Medicare and we call Medicare Advantage, an Advantage Plan. At least that is my experience talking with other people. Not everyone understands what the other person means when they use one of those words and may interpret the meaning different from what the other meant.

Both Medicare and Advantage Plans (see my above terminology) are managed at the first level by different management groups. I will add that ultimately, Advantage Plans are required by law to cover what Medicare covers and do ultimately report to Medicare and must abide by Medicare's rules, however vague they might be. Not being an expert, but reading the Medicare website, it would appear that any question about whether a particular medical service is covered, has the same appeal process flowchart once being.

 

[mathjak107]

bottom line is unless you can’t afford govt medicare and a supplement, you can be setting yourself up for quite a bit of aggravation when it comes to something as important as your health.

not to mention the fact hospitals are dropping out all over from getting involved with advantage plans

 

[Another Reader]

The key words are "medically necessary." Advantage insurers hire doctors, often in unrelated fields, to decide procedures and treatments are not "medically necessary." The stories are endless.

 

[Pluperfect]

Only about 11 percent of the denials were appealed, but the vast majority of those appeals succeeded in getting a full or partial reversal of the original denial

in the case i mentioned it went thru the appeals process and was denied repeatedly because it was not able to be determined what govt medicare would have done in this specific case because she didn’t have govt medicare.

But nobody who appeals a denial by their Medicare Advantage plan has "govt medicare," yet the vast majority of those who appeal are successful. How can that be?

 

[oldtrig]

REWahoo a member here suggested I stay away from an advantage plan years ago. He is a wise man . I listened to him and forever grateful I did. I will be age 77 this year and my wife will be 75 . We pay $6200 a year including our part D plan.

 

[mathjak107]

But nobody who appeals a denial by their Medicare Advantage plan has "govt medicare," yet the vast majority of those who appeal are successful. How can that be?

because the insurer tries to duck out of paying and hopes you let it slide…

for everyone that they deny that doesn’t appeal it goes right to their profit bucket

 

[Pluperfect]

Look out for clauses that say one can go to any Medicare Participating provider - these are often very gratuitous marketing slogans, and the reality is care received out of network is NOT a cake walk.

Can you expand on this?

I'm seeing more and more Medicare Advantage PPO plans that say you can see any provider that accepts Medicare (with possibly a higher copay). I've seen some that say you can see any provider who accepts Medicare and agrees to bill the Advantage plan directly.

How does this work? What I really don't understand is how much the provider gets paid. I assume that if a provider is not in the Advantage plan's provider network, the provider doesn't have a negotiated rate with the Advantage plan. Can the provider bill whatever he wants and the Advantage plan pays it? Why would an Advantage plan agree to that, even if they're getting a higher copay from their member? That higher copay is most likely not going to cover the difference. Do the Advantage plans take a loss on those, hoping it doesn't happen often, in exchange for marketing a very attractive feature?

Or does a requirement that the provider agrees to bill the Advantage plan mean the provider can charge only the Medicare approved amount? But not all plans explicitly have that language about the provider agreeing to bill the Advantage plan.

And why would a provider do that, especially if all he's going to get is the Medicare approved amount? He can get that with traditional Medicare patients, without the extra hassle of billing an Advantage plan he's chosen not to work with.

If the provider can bill whatever he wants, then maybe that could lead him to endure the hassle of billing the Advantage plan if he's going to get paid $1,000 for something Medicare would reimburse at $150. But then you get back to why an Advantage plan would agree to pay the $1,000.

And while I'm at it, what do you know about the pre-approval process? How does that insert itself in the process with an Advantage PPO plan allows you to see any provider that accepts Medicare?

 

[Pluperfect]

because the insurer tries to duck out of paying and hopes you let it slide…

No, I'm asking how anyone wins. You said your friend lost because "it was not able to be determined what govt medicare would have done in this specific case because she didn’t have govt medicare." I'm pointing out that nobody who's appealing has "govt medicare" and yet some win.

 

[mathjak107]

well basically you throw the dice in that case and hope your argument is better then theirs…not everyone is approved for what medicare wouldn’t even have challenged .

but you can’t prove that in your case . so like anything you have to challenge, you hope for the best and give it your best shot

 

[ShokWaveRider]

The majority of Advantage plan subscribers are poor or low income and are less likely to argue in their defense. The Insurance companies think that and bank on it. They are also a lot less likely to afford a lawyer to fight for them.

REMEMBER, company sponsored MA plans are a different animal than those pitched by has been celebrities offering Gym memberships.

 

[mathjak107]

just so you know , our high deductible humana f plan includes silver sneakers .

i pay 100 a month and it covers two gyms i belong to .one used to cost me 60 and the other 35 .

it’s amazing.

people think only advantage plans offer that , but nope we get it with govt medicare and our supplement

 

[MichaelB]

I'm seeing more and more Medicare Advantage PPO plans that say you can see any provider that accepts Medicare (with possibly a higher copay). I've seen some that say you can see any provider who accepts Medicare and agrees to bill the Advantage plan directly.

Yes, my mum has a Medicare Advantage plan like this. She can see any physician that is enrolled in Medicare and accepts assignment.

How does this work? What I really don't understand is how much the provider gets paid. I assume that if a provider is not in the Advantage plan's provider network, the provider doesn't have a negotiated rate with the Advantage plan. Can the provider bill whatever he wants and the Advantage plan pays it? Why would an Advantage plan agree to that, even if they're getting a higher copay from their member? That higher copay is most likely not going to cover the difference. Do the Advantage plans take a loss on those, hoping it doesn't happen often, in exchange for marketing a very attractive feature?

CMS pays the insurer a fee to provide Medicare coverage to the policyholder. These are profitable plans for insurers.

If the provider can bill whatever he wants, then maybe that could lead him to endure the hassle of billing the Advantage plan if he's going to get paid $1,000 for something Medicare would reimburse at $150. But then you get back to why an Advantage plan would agree to pay the $1,000.

Health care providers agree to accept Medicare rates.

And while I'm at it, what do you know about the pre-approval process? How does that insert itself in the process with an Advantage PPO plan allows you to see any provider that accepts Medicare?

First, just to be clear, not all MA plans are PPOs. Even a PPO can ask for some preapprovals, and many do. They might pay for specialist visits, such as an ophthalmologist, without any preapproval, but demand a preapproval for hospitalization or surgery.

Many Medicare Advantage plans also provide pharmaceutical coverage, and a policyholder may find herself responsible for large coinsurance costs.

I agree with many others here that favor traditional Medicare with a supplement instead of MA. It can be pricey, though, and some people even with resources are not concerned with that.

 

[Pluperfect]

well basically you throw the dice in that case and hope your argument is better then theirs…not everyone is approved for what medicare wouldn’t even have challenged .

but you can’t prove that in your case . so like anything you have to challenge, you hope for the best and give it your best shot

If what you said is true, that your friend lost the appeal because "it was not able to be determined what govt medicare would have done in this specific case because she didn’t have govt medicare," then the Advantage plan would argue that in every single appeal and would win every single appeal because none of their members have "govt medicare."

 

[mathjak107]

If what you said is true, that your friend lost the appeal because "it was not able to be determined what govt medicare would have done in this specific case because she didn’t have govt medicare," then the Advantage plan would argue that in every single appeal and would win every single appeal because none of their members have "govt medicare."

you are stretching things ….. i can only speak for an actual case .

but evidently all those hospitals dropping advantage plans because of high denial rates are seeing it too

hey you want one , buy one …

 

[Pluperfect]

Yes, my mum has a Medicare Advantage plan like this. She can see any physician that is enrolled in Medicare and accepts assignment.

By "accepts assignment" do you mean they agree to bill the Advantage? Or is there a difference between accepting assignment and agreeing to bill the Advantage plan? I've seen requirements that specify that the provider must agree to bill the Advantage plan, but not on every plan I've looked at.

But it makes me wonder if a provider accepts Medicare and therefore obviously agrees to be paid at the Medicare rate, if the provider refuses to bill the Advantage plan, could the patient pay up front himself, and seek reimbursement from his Advantage plan? But how much would the patient pay? I think the Medicare-approved amount doesn't get determined until claims are filed.

Regardless, if a person is a member of a Medicare Advantage PPO plan that allows its members to see any provider that accepts Medicare, this seems to eliminate the most commonly cited bugaboo of Advantage plans--the network.

The other bugaboo (and maybe the ONLY other bugaboo) is pre-approvals.

First, just to be clear, not all MA plans are PPOs. Even a PPO can ask for some preapprovals, and many do. They might pay for specialist visits, such as an ophthalmologist, without any preapproval, but demand a preapproval for hospitalization or surgery.

How do pre-approvals work? I assume if you have an HMO everything has to go through your primary care physician. But what if a person with a Medicare Advantage PPO plan sees a specialist who says, "You need surgery tomorrow"? The Advantage plan doesn't even know the member has seen this doctor, and doesn't know the surgery is planned. How would pre-approval work then? That what I meant when I asked how pre-approvals get "inserted" into the process.

And if the Advantage member is seeing an out-of-network doctor, the doctor doesn't even have a relationship with his patient's insurance company, but is apparently being forced to deal with an Advantage plan they have chosen not to contract with. Why would they put up with that?

 

[sengsational]

Medicare Advantage plans have exceptions for emergencies, so the surgery tomorrow thing should be covered regardless of where or if pre-approved. Of course that's another way plans save money...they claim an emergency shouldn't have been considered an emergency.

 

[Pluperfect]

Medicare Advantage plans have exceptions for emergencies, so the surgery tomorrow thing should be covered regardless of where or if pre-approved.

Okay, say the doctor says the patient needs surgery soon and the patient can have it done either next week or, hold on, there's an opening tomorrow.

 

[sengsational]

^ By definition, if the topic of scheduling comes up, it's not an emergency.

 

[CRLLS]

There are several levels of appeals and it matters not if it is Traditional Medicare or an Advantage plan. They are defined by the Office of Medicare Hearings and Appeals. The first 2 levels are unique to the plans. Levels 3,4 and 5 are common regardless of Traditional Medicare or Advantage plan.

https://www.hhs.gov/about/agencies/omha/the-appeals-process/index.html

 

[Ian S]

because the insurer tries to duck out of paying and hopes you let it slide…

or die.